Alzheimer's Disease Brain Phenotypes are Age-dependent

A widespread view of neurodegenerative disorders, including Alzheimer's Disease (AD), frames their effects as accelerated aging, with the brain-age gap (BAG, the deviation of predicted 'brain age' from chronological age) as a staple biomarker. However, BAG relies on a fundamental, untested assumption: that AD can be identified via age-invariant brain phenotypes. Using invariant representation learning on brain MRI from 44,178 individuals, we created neural representations that optimally convey age information (age-aware) or conversely remove it (age-invariant) while minimizing reconstruction distortion. We provide the first causal evidence that age information is necessary in brain biomarkers for AD detection: age-aware representations achieve competitive state-of-the-art performance and significantly outperform age-invariant ones (0.84 vs. 0.77 AUC, p < 0.001, with external validation). This necessity reveals a conceptual flaw in BAG: by subtracting chronological age, it discards the very information essential for accurate detection. Using conditional decoders to simulate aging trajectories, we found that healthy aging and AD operate along multiple independent anatomical dimensions (deep gray matter, frontoparietal, temporal). AD patients diverge from rather than accelerate healthy aging, showing pathological temporal shifts alongside, remarkably, relative frontoparietal preservation. Furthermore, representational similarity analysis suggests that even models pretrained on non-age tasks (e.g., sex or BMI) implicitly converge toward age-related features when optimized for AD. Given that the AD phenotype cannot be decoupled from age, our results establish a hard limit for age-independent biomarkers and favor multidimensional models that preserve aging structure over unidimensional summaries like BAG.